=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790288967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KILOLANI COUNSELING AND MINDFULNESS SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2018
-----------------------------------------------------
Last Update Date | 03/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 321 N KUAKINI ST STE 807
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96817-2395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-282-2564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 609 KUMUKAHI PL
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96825-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-282-2564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. LUCAS MORGAN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 808-282-2564
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | PSY1630
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------